Provider Demographics
NPI:1326003229
Name:PROVOST, GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:PROVOST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9111 MAHALO DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-7863
Mailing Address - Country:US
Mailing Address - Phone:714-401-9117
Mailing Address - Fax:
Practice Address - Street 1:17100 EUCLID ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4004
Practice Address - Country:US
Practice Address - Phone:714-979-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79498207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G794980Medicaid
CAG79498Medicare PIN
CA00G794980Medicaid